title: Micro-dissection testicular sperm extraction as an alternative for sperm acquisition in the most difficult cases of Azoospermia: Technique and preliminary results in India.
abstract: BACKGROUND
  Non-obstructive azoospermia (NOA) is an unfavorable prognostic condition for male infertility since spermatogenesis is disrupted. Sperm retrieval (SR) coupled with intracytoplasmic sperm injection (ICSI) is the only option for men with NOA who seek fertility. Among the SR techniques, microdissection testicular sperm extraction (micro-TESE) has been applied with encouraging results.
  
  
  OBJECTIVE
  We describe how we implemented the micro-TESE procedure and present initial micro-TESE experience in a group of men with NOA and poor prognosis for SR.
  
  
  METHODS
  Case series of men with NOA treated in a tertiary healthcare center.
  
  
  METHODS
  An Assisted Reproductive Technology (ART) facility was setup to perform SR using microsurgery. Fourteen men with NOA and previous failed retrievals or unfavorable histologic results underwent micro-TESE while their female partners received ovarian stimulation for oocyte pickup (OCP). Micro-TESE was performed the day prior to OCP and testicular sperm were used for sperm injections. We assessed retrieval rates and ICSI outcomes.
  
  
  METHODS
  Outcomes of SR and ICSI were analyzed descriptively. Mann-Whitney and Fisher exact test were used to compare characteristics of men with successful and failed SR.
  
  
  RESULTS
  The success of micro-TESE was 50.0% with no major complications. A clear microscopic distinction between enlarged and collapsed seminiferous tubules was seen in 35.7% of the cases, and sperm were retrieved in all but one of these cases. Patients with successful and failed retrieval did not differ with respect to baseline characteristics, use of medical therapy, presence of varicocele, and testicular histology. Sperm injections resulted in normal fertilization and embryo cleavage of 64% and 75%, respectively. A total of five transfers with an average of 1.5 embryos resulted in a cumulative clinical pregnancy rate per ICSI cycle of 28.6%, with an implantation rate of 33.3%.
  
  
  CONCLUSIONS
  We were successful in integrating the micro-TESE procedures to the in vitro fertilization (IVF) laboratory. Our initial experience with micro-TESE applied to the most difficult cases of azoospermia is reassuring.
authors.affiliation: CRAFT Hospital and Research Centre, Kodungalloor, Kerala, India.
authors.forename: Mohamed C
authors.initials: MC
authors.lastname: Ashraf
authors.forename: Sankalp
authors.initials: S
authors.lastname: Singh
authors.forename: Dharma
authors.initials: D
authors.lastname: Raj
authors.forename: Sujatha
authors.initials: S
authors.lastname: Ramakrishnan
authors.forename: Sandro C
authors.initials: SC
authors.lastname: Esteves
keywords: Assisted reproductive techniques; azoospermia; male infertility; microsurgery; sperm retrieval techniques; spermatozoa; sterility; testis